The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HARRIS REGIONAL HOSPITAL 68 HOSPITAL RD SYLVA, NC 28779 Oct. 6, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
Based on policy and procedure review, medical record review, video recording review, observations and staff interviews, the hospital's Governing Body failed to provide oversight and have systems in place to ensure the protection of patients' rights and an organized nursing service to ensure the safety of suicidal patients in the emergency department.

The findings include:

1. The hospital failed to promote and protect patients' rights by failing to ensure a safe setting for behavioral health patients in the Emergency Department.

~cross refer to 482.13 Patient Rights' Condition: Tag 0115.

2. The hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff assessed, supervised and monitored suicidal patients in the emergency department to ensure a safe environment.

~cross refer to 482.23 Nursing Services Condition: Tag 0385.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on policy and procedure review, medical record review, video recording review, observations and staff interviews, the Emergency Department (ED) nursing staff failed to ensure a safe setting for behavioral health patients in the Emergency Department.

The findings include:

The Emergency Department (ED) nursing staff failed to ensure a safe setting for patient care in the Emergency Department for 5 of 14 suicidal patients reviewed (#9, #24, #19, #21, #22).

~cross refer to 482.13(c)(2) Patient Rights' Standard: Tag A0144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, video recording review, observations and staff interviews, the Emergency Department (ED) nursing staff failed to ensure a safe setting for patient care in the Emergency Department for 5 of 14 suicidal patients reviewed (#9, #24, #19, #21, #22).

The findings include:

Review of the Hospital's Policy titled "Suicide Risk and Safety Interventions", Last Revised: 10/2015, revealed "FREQUENCY OF ASSESSMENT: All patients (excluding non-procedural diagnostic laboratory and radiology visits) will be screened for risk of self-harm or suicide. All emergency department patients will be screened with each visit. SCREENING AND FOLLOW-UP: ...All positive suicide risk screenings, in which a patient answers 'yes' to one of the screening questions, will be followed-up with a comprehensive suicide risk assessment, to be completed by the provider or a specially trained staff. *All patients with a primary diagnosis or chief complaint related to substance abuse, and/or mental or emotional illness, will automatically receive a comprehensive risk assessment. EMERGENCY DEPARTMENT SAFETY INTERVENTIONS ...Supervision/Observation: When a patient is found to be at risk for suicide or self-harm, the provider and clinical staff will work together to determine the level of supervision necessary to maintain patient safety. At a minimum, the patient will be directly observed at least every 15 minutes. *At any time, clinical staff may increase the level of observation to ensure patient safety. However, the level of observation must not be decreased without a provider order. *The presence of family members or forensic personnel does not eliminate the need for observation by clinical staff. Clinical staff must carry out the ordered level of supervision, despite the presence of others. LEVELS OF OBSERVATION...1:1 (one-to-one) Observation Staff must remain within arm's length of the patient at all times, obtaining relief as needed. The patient is at imminent risk and there is imminent danger of suicide, and patient behavior may demonstrate: *Verbalizing clear intent for self-harm *Concrete and viable plan *Recent attempts at suicide by lethal method *Attempting to elope INTERVENTIONS Proximity: When possible, the patient will be placed in a room close to the nurses's station...Belongings: Patient belongings will be collected by security staff or clinical staff when security is unavailable (see CONTRABAND LIST)... CONTRABAND LIST When an ...emergency department patient is identified to be at risk for self-harm or suicide, items which pose a risk to safety will be removed from their possession...Items that pose a risk to safety include, but are not limited to:...Belts..."

1. Review of hospital security log/incident reports on 10/04/2016 revealed an incident report dated 08/26/2016 which read "On Friday, August 26, 2016 at approximately 01:05 hrs. Security was dispatched to ED (Emergency Department) #13 (room number) in reference to collecting patient belongings... Upon arrival R/O (reporting officer) Name (SO #1) and Security officer Name (SO #2) attempted to enter patient Name (Pt #9's) room, we found patient sitting on the floor against the door. Officer Name (SO #2) knocked on the door with no response from the patient. Officer Name (SO #2) and Officer Name (SO #1) then pushed the door open scooting patient out of the way. Upon entry Security Officers found the patient on the floor with a belt around his neck and door handle. At this time Officer Name (SO #2) removed the belt from the door and patients neck. Mr. Name (Pt # 9) appeared to be unconscious at the time of entry. Officer Name (SO #1) yelled for a nurse to assist, nurses Name (RN #3) and Name (RN #4) responded along with E.D. (Emergency Department) Physician Dr. Name (MD #5). Security then assisted medical staff getting the patient onto the bed. Security then collected patient Name (Pt #9's) belongings which consist of (2) bags of clothes. Collection was witnessed by Officer Name (SO #2). Patient was unable to sign valuables sheet. Belongings were then placed in Security Cabinet #1. Security then resumed normal duties."

Review of the closed medical record on 10/04/2016 for the patient identified in the Security Officer's Log/Incident Reports on 08/26/2016 revealed a [AGE] year-old (Patient #9) presented on August 26, 2016 at 0020 with a chief complaint of depression and suicidal thoughts with a plan to hang himself. Review of the triage nursing notes dated 08/26/2016 at 0020 revealed ESI (acuity) 2 (urgent). Further review of triage nursing notes dated 08/26/2016 at 0025 revealed "History Historian: patient. Arrived with police from home. Onset: just prior to arrival. SOCIAL HX (history): Smoker current status unknown (smokeless tobacco. Heavy alcohol use. SELF HARM ASSESSMENT: A self harm assessment was performed. The patient answered 'yes' to the question(s) 'Have you recently felt down, depressed, or hopeless?', 'Have you noticed less interest or pleasure in doing things?', 'Do you have thoughts of harming or killing yourself?' and 'Are you here because you tried to hurt yourself?'...SUICIDE RISK ASSESSMENT (SAD PERSONS score - an acronym based on 10 suicide risk factors): 7. The patient is male and less than 19 or greater than [AGE] years old, reports history of depression, admits to excessive alcohol and/or drug use, displays loss of rational thinking, has no social support and has an organized plan for suicide." Review of medical record for Pt #9 revealed no available documentation of a comprehensive suicide risk assessment completed by the provider or a specially trained staff. Review of nursing physical assessment on 08/26/2016 at 0026 revealed "...patient's speech was slurred, loud and repetitive. Patient appears calm and cooperative. Appears agitated, animated and bizarre. Good eye contact..." Review of nursing progress notes dated 08/26/2016 at 0027 revealed "Suicide Precautions initiated: a safety sweep of the room has been completed. Room made safe and stripped of hazardous items. Continuous one on one supervision, police officer at bedside, checks performed every 15 minutes. Patient placed in paper scrubs. ED (Emergency Department) physician has been notified ...Call light placed in reach ..." Review of Physician's Notes dated 08/26/2016 at 0032 revealed "HISTORY OF PRESENT ILLNESS Chief Complaint: depression., thoughts of self-harm - by hanging himself. This started just prior to arrival. Pt called 911 told staff he planned to hang himself. Officer arrived to pt's house - he was sleeping in a chair. Pt did have a cord tied to his truck hood - which pt says he planned to hang himself with and is still present. At its maximum, severity described as severe. When seen in the E.D., severity described as severe...PHYSICAL EXAM Vital Signs: Have been reviewed. Blood pressure normal..." Review of Vital Signs dated 08/26/2016 at 0042 revealed "BP (blood pressure): 167/109. HR (heart rate): 95. RR (respiratory rate): 22. O2 (oxygen) saturation: 95%. Temp. (temperature): 98.4 F (Fahrenheit)." Review of nursing progress notes dated 08/26/2016 at 0100 revealed "Pt (Patient #9) was found hanging from his neck by his belt by security. The belt was removed. The pt (patient) appeared unconscious. He regained consciousness within 45 seconds. Dr. Name (MD #5) was called to room and he (pt #9) was moved to hall 2 (Hall bed 2 near nurse's station) for increased monitoring. No lasting harm has been identified." Review of Physician's Orders dated 08/26/2016 at 0113 revealed orders for lab tests (25 minutes after pt's attempted suicide and 53 minutes after patient's arrival in the ED). Further review of Physician's Orders dated 08/26/2016 at 0223 revealed an order for One on One Observation for Pt #9 (95 minutes after pt's attempted suicide). Further review of nursing notes dated 08/26/2016 at 0239 revealed documentation by RN #6 for 0115 which read "Reassurance given. Suicide precautions initiated...The patient reports anxiety and restlessness..." Review of nursing progress notes dated 08/26/2016 at 0418 revealed documentation of a referral for psychiatric evaluation made to Name of Mental Health Community Services. Review of Physician's Notes not dated/timed revealed "PROGRESS AND PROCEDURES Course of Care: PT TRIED TO HANG HIMSELF IN ROOM. THIS OCCURRED AS PT WAS ALREADY IN HIS SCRUBS - WHILE SECURITY WAS ENROUTE TO COLLECT HIS BELONGINGS. ABG (lab test) COLLECTED AFTER EVENT - BLOOD GAS NORMAL. IVC (Involuntary Commitment) PAPERS COMPLETED." Further review of Physician's Notes revealed next documentation on 08/26/2016 at 0549 which read "pt awaiting Psy (psychiatric) eval (evaluation)." Review of nursing progress notes at 0738 revealed "...One on one sitter is with pt (Name)...After CNA moved pt from hallbed 2 back to room 12, he became upset that we have given him paper sheets and placed paper trash bag in can. One on one sitter maintained after placing pt back in room 12." Review of Vital Signs record dated 08/26/2016 at 0935 revealed blood pressure of 177/102, heart rate 72, respirations 18 and O2 Saturation 97%. Review of nursing progress notes dated 08/26/2016 at 0940 revealed "Pt vital signs assessed. MD notified of hypertension (high blood pressure). Orders given for po Clonidine 0.1 mg (blood pressure medication)..." Review of psychiatric evaluation dated 08/26/2016 at 0945 revealed "...under IVC for calling LE (law enforcement) stating he was going to hang himself. He had a drop cord tied around his lifted truck and intended to hang himself as his best friend did earlier this month. He (pt #9) reported to police and to ED (emergency department) staff that he intended to kill himself and attempted again to kill himself in the ED, with his belt tied around the door knob. For this reason, per Safe T risk assessment, Name (pt #9) is considered a severe risk to himself..." Further review of nursing progress notes at 0951 revealed Clonidine po 0.1 mg given. Review of Vital Signs record dated 08/26/2016 at 1109 revealed blood pressure 147/94 and heart rate 63. Review of Vital Signs record dated 08/26/2016 at 1740 revealed discharge vital signs blood pressure 121/87, heart rate 68, respirations 18, O2 Saturation 98% and temperature of 98.7 F. Review of Discharge Summary revealed Pt #9 was transferred to a mental health hospital on [DATE] at 1742.

Review on 10/06/2016 of the ED back hallway camera video recording revealed CNA #8 carrying one of the patient's belongings bags (second bag carried by patient #9) accompanied by local law enforcement officers (LEO #9 and LEO #10) escorting patient (#9) from Hall B bed (front of ED at nurse's station) to ED room #13 (back hallway with no visual of nurse's station) at 0028. The CNA exited room #13 with room door left open at 0030 without the pt's belongings bags and returned briefly at 0042. The CNA left the room with the two law enforcement officers (LEO #9 and LEO #10) at 0042 with the room door left open and again without the pt's belongings bags. The video revealed the patient walking in room, peeping out the door at 0044 and then pt #9 shut the room door. The video revealed Security Officers (SO #1 & SO #2) walking down the back hallway towards ED room #13. The Security Officers stopped at the Oxygen Supply Room/Patient Video Monitor room, opened door, looked in room, and then proceeded to ED room #13. The Security Officers stopped at the closed door to ED room #13 and looked through glass window on door. The Security Officers pushed the door open and then SO #1 stepped into the hallway and appeared to be yelling down the hallway. ED physician (MD #5), ED Registered nurses (RN #3, RN #4) came down the hallway and joined Security Officers (SO #1 and SO #2) in the room at 0048. At this same time a law enforcement officer (LEO #11 emerged from behind the closed door of the Oxygen Supply Room/Patient Video Monitor Room (located just on the other side of an exit stairwell from Pt #9's room) and stood outside the door of ED room #13. The video revealed MD #5, RN #3, RN #4, SO #1 and SO #2 exited Pt #9's ED Room #13 and shut the pt's room door behind them. The video revealed the Security Officers (SO #1 and SO #2) removed the pt's personal belongings bags and carried them up the hallway towards the nurse's station. The law enforcement officer (LEO #11) returned to the oxygen supply/patient video monitor room. The video revealed RN #3 returned to look through the window of pt #9's room at 0052. The night shift nursing assistant (CNA #8) documented every 15 minute observations from 08/26/2016 at 0030 through 08/26/2016 at 0645. The ED back hallway camera video recording revealed Pt #9 remained in ED room
#13 with door closed with no one-on-one monitoring or 15 minutes observations and was moved to Hall bed 2 at 0144 (56 minutes after patient located hanging from door knob).

Interview with AS #12 ( Administrative Staff) during tour on 10/04/2016 at 1350 revealed old room 13 (where incident occurred) had been converted into an office because of the glass window in the door. Interview revealed the office (new room 13) was originally located directly across the hall from the old room 13. Interview revealed the old office space was now the new room 13. Interview revealed camera's capable of recording for viewing were located in the hallway outside of room 13. Interview revealed the staff have the ability to monitor the camera's located in the rooms from the oxygen supply/patient video monitor room (located in the back hallway of the ED) and from a monitor located in the front of the ED at the registrar/secretary-CNA desk. Interview revealed law enforcement officers usually use the patient video monitor room when they are staying with an Involuntary Committed Patient. Interview revealed there is not always someone watching the patient room monitors.

Interview with SO #1 and SO #2 (Security Officer) on 10/05/2016 at 1800 revealed they were called to the ED to collect and secure a patient's belongings. Interview revealed the nursing staff will usually place the pt's belongings in the oxygen/patient room video monitoring room and they pick up the belongings from the monitor room. Interview revealed the patient (#9) had just been moved from Hall Bed 2 to ED 13 (old room). Interview revealed they met the two law enforcement officers (LEO #9 & LEO #10) walking back up the hallway towards the main part of the ED as they were walking down the hallway towards the patient's room. Interview revealed they had a brief conversation with the LEO's and proceeded to the patient's room. Interview revealed they knocked on the pt's door and did not get an answer, so they looked through the glass and noticed the pt was sitting on the floor up against the door. Interview revealed they pushed the door open and found patient with a belt tied around the door knob and around his neck. Interview revealed they removed the belt from the patients neck and from around the door knob. Interview revealed they laid patient on the floor and one of them stepped into the hallway and yelled for help. Interview revealed assistance arrived within seconds and they placed patient on the stretcher in the room. Interview revealed there was a detention officer in the monitor room during this incident, but did not see the patient place the belt around his neck or the door. Interview revealed they did not see any visible marks on the patient. Interview revealed the patient was in paper scrubs and the patient had two personal belongings bags in the room. Interview revealed they picked up the two belongings bags and carried them to the security cabinet. Interview revealed they did not recall if or when the patient was moved to another bed.

Interview with LEO #10 on 10/05/2016 at 1830 revealed the patient (#9) was carrying one belongings bag and the nursing staff were carrying the second bag. Interview revealed the patient and nursing staff carried the bags to the patient's room.

Interview with CNA #8 on 10/05/2016 at 1835 revealed "since patients' (#9) first visit I have
attended one RCA (Root Cause Analysis) meeting. We discussed what we could do better for suicidal patients in the Emergency Department (ED)." Interview revealed all patients brought into the ED by law enforcement are initially placed in Hall Bed 2. Interview revealed "I will sit with patients until a sitter can be reached." Interview revealed the time to obtain a sitter varies and can take up to a couple of hours. Interview revealed "I assisted pt (#9) to the bathroom from Hall Bed 2 to obtain a urine sample. I cleaned the patient up and had him change into paper scrubs." Interview revealed she accompanied the pt and Law Enforcement Officer (LEO) to ED room 13. Interview revealed the patient had 2 personal belongings bags. Interview revealed LEO #9 carried both personal belongings bags to the patient's room. Interview revealed "When I left the room, both officers were still in the room."

Interview with RN #3 (Registered Nurse) on 10/05/2016 at 1835 revealed "He (pt #9) had tried to hang himself, but he got a phone call that interrupted his plans. We were very, very busy that night and heard Name of Security Officer hollering from down the back hallway. Several nurses and the physician ran down hallway to assist." Interview revealed the hospital issued a new policy/procedure to place on patient's chart to better assess the patients' needs. Interview revealed the patient is rated on a numerical system. Interview revealed the providers use the number value to evaluate need for observation. Interview revealed the provider completes the Mental Health evaluation immediately following the nursing assessment. Interview revealed the patient's belongings are removed from the patient's room. Further interview revealed a curtain for privacy has been placed in the bathroom so the nurses can stand outside the door and still be able to hear the patient in the bathroom. Interview revealed more emphasis on safe environment since incident with Pt #9.

Interview with RN #4 on 10/05/2016 at 1845 revealed "We try to get patients back and collect labs before we move them to the back hallway rooms. Trouble is when we get three 1:1 patients at one time. Sometimes we have 1 officer with 2 patients. The officer sits in the video monitor room. The RN, CNA or hospital security staff sit outside the room door. No designated CNA. The ED CNA has lots of duties as they function as a Unit Secretary and Nursing Assistant." Interview revealed the only training she had received since the incident was during a staff meeting when the director read a policy to the staff.

Interview with AS #12 on 10/05/2016 at 1010 revealed nursing staff are expected to clear rooms of any hazards and observe the patients to prevent injury or elopement. Interview revealed a comprehensive risk assessment should be completed on all patients with a positive suicide risk screening. Interview confirmed the nursing staff did not follow hospital policy for completing a comprehensive risk assessment for patient #9.

Interview with AS #7 on 10/06/2016 at 1010 revealed "Policy changes have not been made. The policies were discussed with ED staff on 08/30/2016 and 08/31/2016 in their monthly staff meetings. Staff resource changes have not been changed in the policy for one-on-one observations issues. Resource issue plan discussed with CEO on 10/05/2016. He supports need for resource bank." Interview revealed the hospital had a "Team Help" that was put in place approximately 4 months ago to assist staff with getting help when needed. Interview revealed the staff must contact the House Supervisor before activating the "Team Help". Interview revealed the staff received "Team Help" training via online computer module, in emails and patient safety rounds. Interview revealed the "Team Help" had only been used once over the past 4 months.

2. Open medical record review of Patient #24 revealed a [AGE] year-old male that (MDS) dated [DATE] at 0200 with a chief complaint of suicidal ideations/attempt with a plan of "driving off a mountain". Review of comprehensive suicide risk assessment completed on 10/06/2016 at 0234 revealed Pt #24 had a weak desire to live, a strong desire to end his life, was thinking about harming himself during assessment, suicidal thoughts intrusive or disruptive to his normal thinking, thoughts lasted a long time, is highly likely to act of these thoughts and has a plan to harm himself by "driving off a mountain". Further review revealed Pt #24 had attempted suicide in the past by cutting his wrist/arm. Review revealed Pt #24 had a suicide risk score of "56" indicating his risk was high and recommended level of observation was one-on-one. Review of Behavioral Health Order Set revealed a physician's order dated 10/06/2016 at 0230 for one-on-one observation level.

Observation during tour of the emergency department on 10/06/2016 at 1215 revealed no direct one-on-one observation by hospital staff for patient #24.

Interview with AS #12 during tour on 10/06/2016 at 1215 revealed the expectation of the staff is to provide a sitter for one-on-one observation if ordered by the physician. Interview revealed the emergency department (ED) charge nurse should assign someone from the ED to sit with the patient until other staffing assistance can be obtained from the director, nurse manager or house supervisor if after hours. Interview confirmed the nursing staff did not follow a physician's order for one-on-one observation for Pt #24.





3. Closed medical record review on October 6, 2016 of Patient #19 revealed a [AGE] year-old female that presented to the emergency department (ED) on 09/26/2016 at 2306 via ambulance with a chief complaint of drug overdose. Review of a physician's medical screening examination initiated at 2318 revealed the patient had ingested 50 tablets of Neurontin (anti-epileptic medication) and the patient had been depressed and had hallucinations. Review revealed the patient was alert and oriented at the time of the examination. Lab studies and an EKG were ordered and completed with normal results. Review of the physician's notes revealed a clinical impression of "Intentional ingestion of medication." Review of nursing notes revealed the patient was moved to Exam Room #12 on 09/27/2016 at 0523 and changed into paper scrubs. Review of the notes revealed at 1102 a safety sweep of the room was completed and the room was made safe. The notes recorded there was a sitter at the bedside at 1102 (11 hours and 56 minutes after arrival). Review revealed the patient was discharged home and departed the ED on 09/27/2016 at 1357. Review of the ED medical record revealed no documentation of a suicide risk screening and comprehensive suicide risk screening and no order for level of safety precautions. Further review of the record revealed no documentation of every 15 minute observation completed.

Interview on 10/06/2016 at 1405 with AS #7 (Director of Quality and Safety) revealed a suicide risk screening is required for all patients that present to the ED and if the patient answers yes to the screening, a more comprehensive suicide risk screening is required. Interview revealed the physician was expected to order a level of observation for any patient found to be at risk and every 15 minute observations were the minimal level of observation required to be done. Interview revealed nursing staff could initiate precautions without a physician's order. Interview with the staff member revealed there was no documentation of a suicide risk assessment and no order for safety precautions. Interview revealed there was no documentation that observations were completed every 15 minutes as required. Interview revealed there was a mandatory training for ED staff on August 30 and 31, 2016 related to completing the suicide risk assessment and precautions. Interview revealed the primary nurse (RN #6) was a traveler and had not attended the training on August 30 and 31, 2016. Interview revealed Patient #19 should have had a suicide risk assessment, safety precautions and observations completed and documented. Interview revealed staff failed to follow the hospital's Suicide Risk and Safety Interventions policy.

4. Closed medical record review on October 6, 2016 of Patient #21 revealed a [AGE] year-old male that presented to the emergency department (ED) on 09/26/2016 at 1636 with a chief complaint of "suicidal thoughts." Review of nursing notes revealed the patient answered "yes" to the question "Do you have thoughts of harming or killing yourself?" on the self-harm assessment. Review revealed a "Comprehensive Suicide Risk Assessment" was completed on 09/26/2016 at 1900 that resulted in a total score of 56. Review of the score of 56 revealed a "high" risk of suicide was present and recommended a "one to one direct observation." Review of the assessment revealed the patient had a suicide plan to overdose on prescribed medications. Review of the "Behavioral Health Order Set" revealed check marks by every 15 minute observations and one to one direct observation. Review revealed the order was signed by the physician on 09/26/2016 at 1852. Review of the record revealed no physician orders written to clarify the level of safety precautions the patient needed. Review revealed the patient was placed on one to one direct observation beginning on 09/26/2016 at 1630 with every 15 minute documentation recorded through 09/30/2016 at 1115. Review revealed the observation was changed to every 15 minute observation on 09/27/2016 at 1611. Review of the record revealed no physician order to change the precautions to every 15 minutes. Review of physician's notes recorded the patient was seen on 09/26/2016 at 1646. Review revealed the patient was depressed with suicidal thoughts and a plan to overdose on medication. Review of physician's notes dated 09/30/2016 at 1045 revealed the patient was re-evaluated by a mental health social worker and was felt to not be suicidal at that time. The notes recorded that the patient agreed to a safety plan and follow up with outpatient mental health. Review revealed the IVC (Involuntary Commitment) was rescinded and the patient was discharged home. The patient departed the ED on 09/30/2016 at 1103.

Interview on 10/06/2016 at 1405 with AS #7 (Director of Quality and Safety) revealed the Comprehensive Suicide Risk Assessment tool is used to determine the recommended observation level. Interview revealed the physician should order the level of observation by using the Behavior Health Order Set. Interview revealed the physician should not have ordered every 15 minute observation and one to one direct observation since they are two different levels of observation. Interview revealed the every 15 minute observation would mean that staff visualize the patient every 15 minutes and the one to one direct observation would mean that staff must remain within arm's length of the patient at all times. Interview revealed the nursing staff should have clarified the physician's order because it is unclear which level of observation was ordered. Interview revealed nursing staff may increase the level of observation at any time to ensure patient safety, but a physician's order is required to decrease the level of observation. Interview confirmed the order for suicide precautions was not clear and there was no physician's order to decrease the level of observation when staff changed the observation from one to one direct observation to every 15 minute observation on 09/27/2016 at 1611. Interview revealed staff failed to follow the hospital's Suicide Risk and Safety Interventions policy.

5. Closed medical record review October 6, 2016 of Patient #22 revealed a [AGE] year-old female that presented to the emergency department (ED) on 09/26/2016 at 1546 with a chief complaint of wants to stop drinking. Review of a physician's medical screening examination initiated at 1650 revealed the patient was in the ED for alcohol detox and had a history of seizures with detox in the past. Review of the physician's notes revealed a clinical impression of "substance dependence problems; dependent on alcohol." Review revealed the patient was discharged home and departed the ED on 09/27/2016 at 1614. Review of the ED medical record revealed no documentation of a suicide risk screening.

Interview on 10/06/2016 at 1405 with AS #7 (Director of Quality and Safety) revealed a suicide risk screening is required for all patients that present to the ED and if the patient answers yes to the screening, a more comprehensive suicide risk screening is required. Interview with the staff member revealed the suicide risk assessment was blank. Interview revealed there was a mandatory training for ED staff on August 30 and 31, 2016 related to completing the suicide risk assessment and precautions. Interview revealed Patient #22 should have had a suicide risk assessment completed and documented. Interview revealed staff failed to follow the hospital's Suicide Risk and Safety Interventions policy.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on policy and procedure review, medical record review, video recording review, observations and staff interviews, the hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff assessed, supervised and monitored suicidal patients in the emergency department to ensure a safe environment.

The findings include:

The Emergency Department (ED) nursing staff failed to assess and monitor a suicidal patient in 5 of 14 suicidal patients reviewed (#9, #24, #19, #21, #22).

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, video recording review, observations and staff interviews, the Emergency Department (ED) nursing staff failed to assess and monitor a suicidal patient in 5 of 14 suicidal patients reviewed (#9, #24, #19,
#21, #22).

The findings include:

Review of the Hospital's Policy titled "Suicide Risk and Safety Interventions", Last Revised: 10/2015, revealed "FREQUENCY OF ASSESSMENT: All patients (excluding non-procedural diagnostic laboratory and radiology visits) will be screened for risk of self-harm or suicide. All emergency department patients will be screened with each visit. SCREENING AND FOLLOW-UP: ...All positive suicide risk screenings, in which a patient answers 'yes' to one of the screening questions, will be followed-up with a comprehensive suicide risk assessment, to be completed by the provider or a specially trained staff. *All patients with a primary diagnosis or chief complaint related to substance abuse, and/or mental or emotional illness, will automatically receive a comprehensive risk assessment. EMERGENCY DEPARTMENT SAFETY INTERVENTIONS ...Supervision/Observation: When a patient is found to be at risk for suicide or self-harm, the provider and clinical staff will work together to determine the level of supervision necessary to maintain patient safety. At a minimum, the patient will be directly observed at least every 15 minutes. *At any time, clinical staff may increase the level of observation to ensure patient safety. However, the level of observation must not be decreased without a provider order. *The presence of family members or forensic personnel does not eliminate the need for observation by clinical staff. Clinical staff must carry out the ordered level of supervision, despite the presence of others. LEVELS OF OBSERVATION...1:1 (one-to-one) Observation Staff must remain within arm's length of the patient at all times, obtaining relief as needed. The patient is at imminent risk and there is imminent danger of suicide, and patient behavior may demonstrate: *Verbalizing clear intent for self-harm *Concrete and viable plan *Recent attempts at suicide by lethal method *Attempting to elope INTERVENTIONS Proximity: When possible, the patient will be placed in a room close to the nurses's station...Belongings: Patient belongings will be collected by security staff or clinical staff when security is unavailable (see CONTRABAND LIST)... CONTRABAND LIST When an ...emergency department patient is identified to be at risk for self-harm or suicide, items which pose a risk to safety will be removed from their possession...Items that pose a risk to safety include, but are not limited to:...Belts..."

1. Review of hospital security log/incident reports on 10/04/2016 revealed an incident report dated 08/26/2016 which read "On Friday, August 26, 2016 at approximately 01:05 hrs. Security was dispatched to ED (Emergency Department) #13 (room number) in reference to collecting patient belongings... Upon arrival R/O (reporting officer) Name (SO #1) and Security officer Name (SO #2) attempted to enter patient Name (Pt #9's) room, we found patient sitting on the floor against the door. Officer Name (SO #2) knocked on the door with no response from the patient. Officer Name (SO #2) and Officer Name (SO #1) then pushed the door open scooting patient out of the way. Upon entry Security Officers found the patient on the floor with a belt around his neck and door handle. At this time Officer Name (SO #2) removed the belt from the door and patients neck. Mr. Name (Pt # 9) appeared to be unconscious at the time of entry. Officer Name (SO #1) yelled for a nurse to assist, nurses Name (RN #3) and Name (RN #4) responded along with E.D. (Emergency Department) Physician Dr. Name (MD #5). Security then assisted medical staff getting the patient onto the bed. Security then collected patient Name (Pt #9's) belongings which consist of (2) bags of clothes. Collection was witnessed by Officer Name (SO #2). Patient was unable to sign valuables sheet. Belongings were then placed in Security Cabinet #1. Security then resumed normal duties."

Review of the closed medical record on 10/04/2016 for the patient identified in the Security Officer's Log/Incident Reports on 08/26/2016 revealed a [AGE] year-old (Patient #9) presented on August 26, 2016 at 0020 with a chief complaint of depression and suicidal thoughts with a plan to hang himself. Review of the triage nursing notes dated 08/26/2016 at 0020 revealed ESI (acuity) 2 (urgent). Further review of triage nursing notes dated 08/26/2016 at 0025 revealed "History Historian: patient. Arrived with police from home. Onset: just prior to arrival. SOCIAL HX (history): Smoker current status unknown (smokeless tobacco. Heavy alcohol use. SELF HARM ASSESSMENT: A self harm assessment was performed. The patient answered 'yes' to the question(s) 'Have you recently felt down, depressed, or hopeless?', 'Have you noticed less interest or pleasure in doing things?', 'Do you have thoughts of harming or killing yourself?' and 'Are you here because you tried to hurt yourself?'...SUICIDE RISK ASSESSMENT (SAD PERSONS score - an acronym based on 10 suicide risk factors): 7. The patient is male and less than 19 or greater than [AGE] years old, reports history of depression, admits to excessive alcohol and/or drug use, displays loss of rational thinking, has no social support and has an organized plan for suicide." Review of medical record for Pt #9 revealed no available documentation of a comprehensive suicide risk assessment completed by the provider or a specially trained staff. Review of nursing physical assessment on 08/26/2016 at 0026 revealed "...patient's speech was slurred, loud and repetitive. Patient appears calm and cooperative. Appears agitated, animated and bizarre. Good eye contact..." Review of nursing progress notes dated 08/26/2016 at 0027 revealed "Suicide Precautions initiated: a safety sweep of the room has been completed. Room made safe and stripped of hazardous items. Continuous one on one supervision, police officer at bedside, checks performed every 15 minutes. Patient placed in paper scrubs. ED (Emergency Department) physician has been notified ...Call light placed in reach ..." Review of Physician's Notes dated 08/26/2016 at 0032 revealed "HISTORY OF PRESENT ILLNESS Chief Complaint: depression., thoughts of self-harm - by hanging himself. This started just prior to arrival. Pt called 911 told staff he planned to hang himself. Officer arrived to pt's house - he was sleeping in a chair. Pt did have a cord tied to his truck hood - which pt says he planned to hang himself with and is still present. At its maximum, severity described as severe. When seen in the E.D., severity described as severe...PHYSICAL EXAM Vital Signs: Have been reviewed. Blood pressure normal..." Review of Vital Signs dated 08/26/2016 at 0042 revealed "BP (blood pressure): 167/109. HR (heart rate): 95. RR (respiratory rate): 22. O2 (oxygen) saturation: 95%. Temp. (temperature): 98.4 F (Fahrenheit)." Review of nursing progress notes dated 08/26/2016 at 0100 revealed "Pt (Patient #9) was found hanging from his neck by his belt by security. The belt was removed. The pt (patient) appeared unconscious. He regained consciousness within 45 seconds. Dr. Name (MD #5) was called to room and he (pt #9) was moved to hall 2 (Hall bed 2 near nurse's station) for increased monitoring. No lasting harm has been identified." Review of Physician's Orders dated 08/26/2016 at 0113 revealed orders for lab tests (25 minutes after pt's attempted suicide and 53 minutes after patient's arrival in the ED). Further review of Physician's Orders dated 08/26/2016 at 0223 revealed an order for One on One Observation for Pt #9 (95 minutes after pt's attempted suicide). Further review of nursing notes dated 08/26/2016 at 0239 revealed documentation by RN #6 for 0115 which read "Reassurance given. Suicide precautions initiated...The patient reports anxiety and restlessness..." Review of nursing progress notes dated 08/26/2016 at 0418 revealed documentation of a referral for psychiatric evaluation made to Name of Mental Health Community Services. Review of Physician's Notes not dated/timed revealed "PROGRESS AND PROCEDURES Course of Care: PT TRIED TO HANG HIMSELF IN ROOM. THIS OCCURRED AS PT WAS ALREADY IN HIS SCRUBS - WHILE SECURITY WAS ENROUTE TO COLLECT HIS BELONGINGS. ABG (lab test) COLLECTED AFTER EVENT - BLOOD GAS NORMAL. IVC (Involuntary Commitment) PAPERS COMPLETED." Further review of Physician's Notes revealed next documentation on 08/26/2016 at 0549 which read "pt awaiting Psy (psychiatric) eval (evaluation)." Review of nursing progress notes at 0738 revealed "...One on one sitter is with pt (Name)...After CNA moved pt from hallbed 2 back to room 12, he became upset that we have given him paper sheets and placed paper trash bag in can. One on one sitter maintained after placing pt back in room 12." Review of Vital Signs record dated 08/26/2016 at 0935 revealed blood pressure of 177/102, heart rate 72, respirations 18 and O2 Saturation 97%. Review of nursing progress notes dated 08/26/2016 at 0940 revealed "Pt vital signs assessed. MD notified of hypertension (high blood pressure). Orders given for po Clonidine 0.1 mg (blood pressure medication)..." Review of psychiatric evaluation dated 08/26/2016 at 0945 revealed "...under IVC for calling LE (law enforcement) stating he was going to hang himself. He had a drop cord tied around his lifted truck and intended to hang himself as his best friend did earlier this month. He (pt #9) reported to police and to ED (emergency department) staff that he intended to kill himself and attempted again to kill himself in the ED, with his belt tied around the door knob. For this reason, per Safe T risk assessment, Name (pt #9) is considered a severe risk to himself..." Further review of nursing progress notes at 0951 revealed Clonidine po 0.1 mg given. Review of Vital Signs record dated 08/26/2016 at 1109 revealed blood pressure 147/94 and heart rate 63. Review of Vital Signs record dated 08/26/2016 at 1740 revealed discharge vital signs blood pressure 121/87, heart rate 68, respirations 18, O2 Saturation 98% and temperature of 98.7 F. Review of Discharge Summary revealed Pt #9 was transferred to a mental health hospital on [DATE] at 1742.

Review on 10/06/2016 of the ED back hallway camera video recording revealed CNA #8 carrying one of the patient's belongings bags (second bag carried by patient #9) accompanied by local law enforcement officers (LEO #9 and LEO #10) escorting patient (#9) from Hall B bed (front of ED at nurse's station) to ED room #13 (back hallway with no visual of nurse's station) at 0028. The CNA exited room #13 with room door left open at 0030 without the pt's belongings bags and returned briefly at 0042. The CNA left the room with the two law enforcement officers (LEO #9 and LEO #10) at 0042 with the room door left open and again without the pt's belongings bags. The video revealed the patient walking in room, peeping out the door at 0044 and then pt #9 shut the room door. The video revealed Security Officers (SO #1 & SO #2) walking down the back hallway towards ED room #13. The Security Officers stopped at the Oxygen Supply Room/Patient Video Monitor room, opened door, looked in room, and then proceeded to ED room #13. The Security Officers stopped at the closed door to ED room #13 and looked through glass window on door. The Security Officers pushed the door open and then SO #1 stepped into the hallway and appeared to be yelling down the hallway. ED physician (MD #5), ED Registered nurses (RN #3, RN #4) came down the hallway and joined Security Officers (SO #1 and SO #2) in the room at 0048. At this same time a law enforcement officer (LEO #11 emerged from behind the closed door of the Oxygen Supply Room/Patient Video Monitor Room (located just on the other side of an exit stairwell from Pt #9's room) and stood outside the door of ED room #13. The video revealed MD #5, RN #3, RN #4, SO #1 and SO #2 exited Pt #9's ED Room #13 and shut the pt's room door behind them. The video revealed the Security Officers (SO #1 and SO #2) removed the pt's personal belongings bags and carried them up the hallway towards the nurse's station. The law enforcement officer (LEO #11) returned to the oxygen supply/patient video monitor room. The video revealed RN #3 returned to look through the window of pt #9's room at 0052. The night shift nursing assistant (CNA #8) documented every 15 minute observations from 08/26/2016 at 0030 through 08/26/2016 at 0645. The ED back hallway camera video recording revealed Pt #9 remained in ED room
#13 with door closed with no one-on-one monitoring or 15 minutes observations and was moved to Hall bed 2 at 0144 (56 minutes after patient located hanging from door knob).

Interview with AS #12 ( Administrative Staff) during tour on 10/04/2016 at 1350 revealed old room 13 (where incident occurred) had been converted into an office because of the glass window in the door. Interview revealed the office (new room 13) was originally located directly across the hall from the old room 13. Interview revealed the old office space was now the new room 13. Interview revealed camera's capable of recording for viewing were located in the hallway outside of room 13. Interview revealed the staff have the ability to monitor the camera's located in the rooms from the oxygen supply/patient video monitor room (located in the back hallway of the ED) and from a monitor located in the front of the ED at the registrar/secretary-CNA desk. Interview revealed law enforcement officers usually use the patient video monitor room when they are staying with an Involuntary Committed Patient. Interview revealed there is not always someone watching the patient room monitors.

Interview with SO #1 and SO #2 (Security Officer) on 10/05/2016 at 1800 revealed they were called to the ED to collect and secure a patient's belongings. Interview revealed the nursing staff will usually place the pt's belongings in the oxygen/patient room video monitoring room and they pick up the belongings from the monitor room. Interview revealed the patient (#9) had just been moved from Hall Bed 2 to ED 13 (old room). Interview revealed they met the two law enforcement officers (LEO #9 & LEO #10) walking back up the hallway towards the main part of the ED as they were walking down the hallway towards the patient's room. Interview revealed they had a brief conversation with the LEO's and proceeded to the patient's room. Interview revealed they knocked on the pt's door and did not get an answer, so they looked through the glass and noticed the pt was sitting on the floor up against the door. Interview revealed they pushed the door open and found patient with a belt tied around the door knob and around his neck. Interview revealed they removed the belt from the patients neck and from around the door knob. Interview revealed they laid patient on the floor and one of them stepped into the hallway and yelled for help. Interview revealed assistance arrived within seconds and they placed patient on the stretcher in the room. Interview revealed there was a detention officer in the monitor room during this incident, but did not see the patient place the belt around his neck or the door. Interview revealed they did not see any visible marks on the patient. Interview revealed the patient was in paper scrubs and the patient had two personal belongings bags in the room. Interview revealed they picked up the two belongings bags and carried them to the security cabinet. Interview revealed they did not recall if or when the patient was moved to another bed.

Interview with LEO #10 on 10/05/2016 at 1830 revealed the patient (#9) was carrying one belongings bag and the nursing staff were carrying the second bag. Interview revealed the patient and nursing staff carried the bags to the patient's room.

Interview with CNA #8 on 10/05/2016 at 1835 revealed "since patients' (#9) first visit I have
attended one RCA (Root Cause Analysis) meeting. We discussed what we could do better for suicidal patients in the Emergency Department (ED)." Interview revealed all patients brought into the ED by law enforcement are initially placed in Hall Bed 2. Interview revealed "I will sit with patients until a sitter can be reached." Interview revealed the time to obtain a sitter varies and can take up to a couple of hours. Interview revealed "I assisted pt (#9) to the bathroom from Hall Bed 2 to obtain a urine sample. I cleaned the patient up and had him change into paper scrubs." Interview revealed she accompanied the pt and Law Enforcement Officer (LEO) to ED room 13. Interview revealed the patient had 2 personal belongings bags. Interview revealed LEO #9 carried both personal belongings bags to the patient's room. Interview revealed "When I left the room, both officers were still in the room."

Interview with RN #3 (Registered Nurse) on 10/05/2016 at 1835 revealed "He (pt #9) had tried to hang himself, but he got a phone call that interrupted his plans. We were very, very busy that night and heard Name of Security Officer hollering from down the back hallway. Several nurses and the physician ran down hallway to assist." Interview revealed the hospital issued a new policy/procedure to place on patient's chart to better assess the patients' needs. Interview revealed the patient is rated on a numerical system. Interview revealed the providers use the number value to evaluate need for observation. Interview revealed the provider completes the Mental Health evaluation immediately following the nursing assessment. Interview revealed the patient's belongings are removed from the patient's room. Further interview revealed a curtain for privacy has been placed in the bathroom so the nurses can stand outside the door and still be able to hear the patient in the bathroom. Interview revealed more emphasis on safe environment since incident with Pt #9.

Interview with RN #4 on 10/05/2016 at 1845 revealed "We try to get patients back and collect labs before we move them to the back hallway rooms. Trouble is when we get three 1:1 patients at one time. Sometimes we have 1 officer with 2 patients. The officer sits in the video monitor room. The RN, CNA or hospital security staff sit outside the room door. No designated CNA. The ED CNA has lots of duties as they function as a Unit Secretary and Nursing Assistant." Interview revealed the only training she had received since the incident was during a staff meeting when the director read a policy to the staff.

Interview with AS #12 on 10/05/2016 at 1010 revealed nursing staff are expected to clear rooms of any hazards and observe the patients to prevent injury or elopement. Interview revealed a comprehensive risk assessment should be completed on all patients with a positive suicide risk screening. Interview confirmed the nursing staff did not follow hospital policy for completing a comprehensive risk assessment for patient #9.

Interview with AS #7 on 10/06/2016 at 1010 revealed "Policy changes have not been made. The policies were discussed with ED staff on 08/30/2016 and 08/31/2016 in their monthly staff meetings. Staff resource changes have not been changed in the policy for one-on-one observations issues. Resource issue plan discussed with CEO on 10/05/2016. He supports need for resource bank." Interview revealed the hospital had a "Team Help" that was put in place approximately 4 months ago to assist staff with getting help when needed. Interview revealed the staff must contact the House Supervisor before activating the "Team Help". Interview revealed the staff received "Team Help" training via online computer module, in emails and patient safety rounds. Interview revealed the "Team Help" had only been used once over the past 4 months.

2. Open medical record review of Patient #24 revealed a [AGE] year-old male that (MDS) dated [DATE] at 0200 with a chief complaint of suicidal ideations/attempt with a plan of "driving off a mountain". Review of comprehensive suicide risk assessment completed on 10/06/2016 at 0234 revealed Pt #24 had a weak desire to live, a strong desire to end his life, was thinking about harming himself during assessment, suicidal thoughts intrusive or disruptive to his normal thinking, thoughts lasted a long time, is highly likely to act of these thoughts and has a plan to harm himself by "driving off a mountain". Further review revealed Pt #24 had attempted suicide in the past by cutting his wrist/arm. Review revealed Pt #24 had a suicide risk score of "56" indicating his risk was high and recommended level of observation was one-on-one. Review of Behavioral Health Order Set revealed a physician's order dated 10/06/2016 at 0230 for one-on-one observation level.

Observation during tour of the emergency department on 10/06/2016 at 1215 revealed no direct one-on-one observation by hospital staff for patient #24.

Interview with AS #12 during tour on 10/06/2016 at 1215 revealed the expectation of the staff is to provide a sitter for one-on-one observation if ordered by the physician. Interview revealed the emergency department (ED) charge nurse should assign someone from the ED to sit with the patient until other staffing assistance can be obtained from the director, nurse manager or house supervisor if after hours. Interview confirmed the nursing staff did not follow a physician's order for one-on-one observation for Pt #24.





3. Closed medical record review on October 6, 2016 of Patient #19 revealed a [AGE] year-old female that presented to the emergency department (ED) on 09/26/2016 at 2306 via ambulance with a chief complaint of drug overdose. Review of a physician's medical screening examination initiated at 2318 revealed the patient had ingested 50 tablets of Neurontin (anti-epileptic medication) and the patient had been depressed and had hallucinations. Review revealed the patient was alert and oriented at the time of the examination. Lab studies and an EKG were ordered and completed with normal results. Review of the physician's notes revealed a clinical impression of "Intentional ingestion of medication." Review of nursing notes revealed the patient was moved to Exam Room #12 on 09/27/2016 at 0523 and changed into paper scrubs. Review of the notes revealed at 1102 a safety sweep of the room was completed and the room was made safe. The notes recorded there was a sitter at the bedside at 1102 (11 hours and 56 minutes after arrival). Review revealed the patient was discharged home and departed the ED on 09/27/2016 at 1357. Review of the ED medical record revealed no documentation of a suicide risk screening and comprehensive risk screening and no order for level of safety precautions. Further review of the record revealed no documentation of every 15 minute observation completed.

Interview on 10/06/2016 at 1405 with AS #7 (Director of Quality and Safety) revealed a suicide risk screening is required for all patients that present to the ED and if the patient answers yes to the screening, a more comprehensive suicide risk screening is required. Interview revealed the physician was expected to order a level of observation for any patient found to be at risk and every 15 minute observations were the minimal level of observation required to be done. Interview revealed nursing staff could initiate precautions without a physician's order. Interview with the staff member revealed there was no documentation of a suicide risk assessment and no order for safety precautions. Interview revealed there was no documentation that observations were completed every 15 minutes as required. Interview revealed there was a mandatory training for ED staff on August 30 and 31, 2016 related to completing the suicide risk assessment and precautions. Interview revealed the primary nurse (RN #8) was a traveler and had not attended the training on August 30 and 31, 2016. Interview revealed Patient #19 should have had a suicide risk assessment, safety precautions and observations completed and documented. Interview revealed staff failed to follow the hospital's Suicide Risk and Safety Interventions policy.

4. Closed medical record review on October 6, 2016 of Patient #21 revealed a [AGE] year-old male that presented to the emergency department (ED) on 09/26/2016 at 1636 with a chief complaint of "suicidal thoughts." Review of nursing notes revealed the patient answered "yes" to the question "Do you have thoughts of harming or killing yourself?" on the self-harm assessment. Review revealed a "Comprehensive Suicide Risk Assessment" was completed on 09/26/2016 at 1900 that resulted in a total score of 56. Review of the score of 56 revealed a "high" risk of suicide was present and recommended a "one to one direct observation." Review of the assessment revealed the patient had a suicide plan to overdose on prescribed medications. Review of the "Behavioral Health Order Set" revealed check marks by every 15 minute observations and one to one direct observation. Review revealed the order was signed by the physician on 09/26/2016 at 1852. Review of the record revealed no physician orders written to clarify the level of safety precautions the patient needed. Review revealed the patient was placed on one to one direct observation beginning on 09/26/2016 at 1630 with every 15 minute documentation recorded through 09/30/2016 at 1115. Review revealed the observation was changed to every 15 minute observation on 09/27/2016 at 1611. Review of the record revealed no physician order to change the precautions to every 15 minutes. Review of physician's notes recorded the patient was seen on 09/26/2016 at 1646. Review revealed the patient was depressed with suicidal thoughts and a plan to overdose on medication. Review of physician's notes dated 09/30/2016 at 1045 revealed the patient was re-evaluated by a mental health social worker and was felt to be not suicidal at that time. The notes recorded that the patient agreed to a safety plan and follow up with outpatient mental health. Review revealed the IVC (Involuntary Commitment) was rescinded and the patient was discharged home. The patient departed the ED on 09/30/2016 at 1103.

Interview on 10/06/2016 at 1405 with AS #7 (Director of Quality and Safety) revealed the Comprehensive Suicide Risk Assessment tool is used to determine the recommended observation level. Interview revealed the physician should order the level of observation by using the Behavior Health Order Set. Interview revealed the physician should not have ordered every 15 minute observation and one to one direct observation since they are two different levels of observation. Interview revealed the every 15 minute observation would mean that staff visualize the patient every 15 minutes and the one to one direct observation would mean that staff must remain within arm's length of the patient at all times. Interview revealed the nursing staff should have clarified the physician's order because it is unclear which level of observation was ordered. Interview revealed nursing staff may increase the level of observation at any time to ensure patient safety, but a physician's order is required to decrease the level of observation. Interview confirmed the order for suicide precautions was not clear and there was no physician's order to decrease the level of observation when staff changed the observation from one to one direct observation to every 15 minute observation on 09/27/2016 at 1611. Interview revealed staff failed to follow the hospital's Suicide Risk and Safety Interventions policy.

5. Closed medical record review October 6, 2016 of Patient #22 revealed a [AGE] year-old female that presented to the emergency department (ED) on 09/26/2016 at 1546 with a chief complaint of wants to stop drinking. Review of a physician's medical screening examination initiated at 1650 revealed the patient was in the ED for alcohol detox and had a history of seizures with detox in the past. Review of the physician's notes revealed a clinical impression of "substance dependence problems; dependent on alcohol." Review revealed the patient was discharged home and departed the ED on 09/27/2016 at 1614. Review of the ED medical record revealed no documentation of a suicide risk screening.

Interview on 10/06/2016 at 1405 with AS #7 (Director of Quality and Safety) revealed a suicide risk screening is required for all patients that present to the ED and if the patient answers yes to the screening, a more comprehensive suicide risk screening is required. Interview with the staff member revealed the suicide risk assessment was blank. Interview revealed there was a mandatory training for ED staff on August 30 and 31, 2016 related to completing the suicide risk assessment and precautions. Interview revealed Patient #22 should have had a suicide risk assessment completed and documented. Interview revealed staff failed to follow the hospital's Suicide Risk and Safety Interventions policy.